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Reliability of Endocervical Curettage in the Diagnosis of High-Grade Cervical Neoplasia and Cervical Cancer in Selected Patients

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Reliability of Endocervical Curettage in the Diagnosis of High-Grade Cervical Neoplasia and Cervical Cancer in Selected Patients ANTICANCER RESEARCH 35: 4183-4190 (2015) Reliability of Endocervical Curettage in the Diagnosis of High-grade Cervical Neoplasia and Cervical Cancer in Selected Patients CHERIF AKLADIOS1, LISE LECOINTRE1, EMMANUELLE BAULON1, VERONIQUE THOMA1, GERLINDE AVEROUS2, MURIEL FENDER3, FRANÇOIS LEFEBVRE4 and JEAN-JACQUES BALDAUF1 Departments of 1Obstetrics and Gynecology, 2Pathology, University Hospital of Hautepierre, Strasbourg, France; 3EVE Association, Graffenstaden, France; 4Methodology and Biostatistics Sector, Public Health Department, Strasbourg University Hospitals, Strasbourg, France Abstract. Aim: To analyze the reliability of endocervical involvement, represents a real difficulty for the colposcopist curettage (ECC) in the diagnosis of high-grade cervical trying to achieve complete visualization, as well as accurate intraepithelial neoplasia and cervical cancer, and to identify sampling by directed biopsy. In such cases, for many risk factors associated with diagnostic underestimation. colposcopists endocervical curettage (ECC) increases the Materials and Methods: A retrospective study was carried-out reliability of the examination and reduces the risk of an involving 445 patients who underwent ECC for: endocervical occult cancer (2-4). Many authors refer to situations where lesion incompletely visible on colposcopy or inaccessible to only EEC helped establish the diagnosis of cancer, either by biopsy; atypical glandular cells on smear, or discrepancy immediate analysis of the curetted sample or secondarily to between colposcopic impression and cytological abnormalities. the analysis of the cone biopsy performed because EEC Results: Comparison between ECC and final diagnosis showed revealed high-grade CIN (1-3, 5-7). Conversely, some a perfect match in 362 patients (81.3%). For 189 patients with authors blame the pain associated with ECC, as well as the pre-cancerous or cancerous endocervical lesions, the sensitivity, frequent difficulties of the pathological interpretation of specificity, and positive and negative predictive values were small fragments without stroma (8-10). Others point-out that 87.3%, 96.9%, 95.4% and 91.9%, respectively. No clinical, ECC is especially contributory in patients who are candidates cytological or colposcopic characteristics were associated with for treatment by excision (11, 12). significantly increased risk of diagnostic underestimation with The aim of our study was to analyze the reliability of ECC. Conclusion: ECC is a very reliable tool for reducing the ECC in the diagnosis of high-grade CIN and cervical number of unnecessary treatments, without increasing the risk cancer, and to identify the risk factors associated with of allowing some lesions to evolve into cancer. diagnostic underestimation in order to provide a safe approach to all patients. In the case of abnormal Papanicolau smear, the two primary objectives of colposcopy are: to identify high-grade cervical Materials and Methods intraepithelial neoplasia (CIN) in order to prevent its progression into an invasive lesion, and to identify This retrospective study included 445 patients who underwent an carcinomas to allow their early treatment. The frequency of ECC in the course of colposcopy and for whom the final endocervical involvement increases with the severity of the histological diagnosis of the endocervix was validated either by the cervical lesion (1, 2). At the same time, the endocervical analysis of a surgical specimen or the data of the cyto-colpo- status of the lesions, whether there is a total or partial histological monitoring obtained in at least two subsequent examinations. Among the 4,432 patients referred to our colposcopy unit between January 1985 and December 2011, because of an abnormal smear or to monitor a cervical lesion, ECCs were Correspondence to: Professor Jean-Jacques Baldauf, Department of performed by two colposcopists, exclusively in non-pregnant Obstetrics and Gynecology, Hospital of Hautepierre, 67098 patients without complete cervical stenosis. Strasbourg Cedex, France. Tel: +33 0388127472, Fax: +33 The colposcopic interpretation was made according to the criteria 0388127457, e-mail: [email protected] defined in Barcelona in 2002 by the International Federation for Cervical Pathology and Colposcopy (IFCPC) (13). Specifically, Key Words: CIN, cervical cancer, colposcopy, endocervical curettage. three situations led to ECC: i) an endocervical lesion incompletely 0250-7005/2015 $2.00+.40 4183 ANTICANCER RESEARCH 35: 4183-4190 (2015) Table I. Correlation between diagnosis by endocervical curettage (ECC) and final endocervical diagnosis. No. of cases ECC diagnosis Final endocervical diagnosis Normal CIN? CIN1 CIN2 CIN3 AIS Micro SCC CAC EAC Total Normal 208 1 14 2 225 CIN1 2 1 22 42 31 CIN2 5 2 5 30 446 CIN3 5 1 4 16 89 115 AIS 1 2 4 7 Micro 1 7 2 212 SCC 2 3 5 CAC 1 2 3 EAC 1 1 Total 222 5 45 52 106 5 2 5 2 1 445 CIN: Cervical intraepithelial neoplasia; CIN?: cervical intraepithelial neoplasia impossible to classify; AIS: adenocarcinoma in situ; Micro: microinvasive squamous cell carcinoma(SCC); CAC: cervical adenocarcinoma; EAC: endometrial adenocarcinoma. Bold values illustrate a perfect match between ECC and final diagnosis. visible or inaccessible to directed biopsy; ii) the presence of atypical diagnosis. Patients participating in this program were informed of the glandular cells on cervical smear; and iii) a discrepancy between the registration and use of their data in accordance with the terms colposcopic appearance and the cervical smear, be it a smear with a validated and authorized by the French National Commission on Data low-grade squamous intraepithelial lesion (SIL) or atypical Processing and Liberty. The Committee for the Protection of Persons squamous cells of undetermined significance (ASC-US) without of the Strasbourg University Hospitals approved this research. T h e apparent lesion at colposcopy, or a smear with atypical squamous diagnostic reliability of ECC was compared with the final cells not excluding high-grade SIL (ASC-H), high-grade SIL, or endocervical diagnosis according to four categories: normal, mild suggestive of squamous cell carcinoma (SCC) if the colposcopic lesions (CIN1), precancerous lesions [CIN2, CIN3 or adenocarcinoma impression was not in favor of severe cervical lesion (i.e. CIN2+). in situ (AIS)], and cancer (microinvasive or invasive, squamous or We excluded six patients from this study whose tissue collected glandular). We considered ECC results as false-positives when a by endocervical curettage was insufficient for histological lesion was found, regardless of its severity, but the histological analysis, and 14 patients lost to follow-up for whom the final analysis of the surgical specimen did not confirm the presence of an histological endocervical diagnosis could not be established. endocervical lesion. Conversely, we considered as false-negative Clinical, cytological and colposcopic characteristics of the results cases in which normal tissue was found with ECC when the excluded patients were not significantly different from those of the endocervical analysis of the surgical specimen revealed a lesion. 445 patients who were included. Precancerous lesions were considered as underestimated when the All ECCs were performed using a Kervokian curette, usually ECC revealed normal tissue or CIN1. Finally, for the diagnosis of without anesthesia. To obtain sufficiently comprehensive tissue cancer, we considered as underestimated the cases in which the ECC material of the endocervical mucosa, samples were consistently showed normal tissue, CIN1-3 or AIS. When the ECC analysis taken at the four quadrants of the cervical canal and placed in a indicated CIN without being able to specify its grade, it was single collection device for histological analysis. In some very rare considered as a true-positive result for final diagnosis of CIN1, and as cases, traction on the cervix with a tenaculum was necessary to underestimated for final diagnosis of precancerous lesions or cancer. increase the accessibility of a misaligned cervix, or to introduce the curette easily in case of partial cervical stenosis. More rarely, in Statistical analysis. Descriptive statistics are tabulated by patient more severe stenosis, it was necessary to open or expand the groups. Continuous variables are summarized by means with cervical os with a scalpel or sharp scissors, which sometimes standard deviation and medians with ranges. Confidence intervals for required local anesthesia. sensitivity, specificity, positive predictive value and negative All cervical biopsies, ECCs, conization and hysterectomy predictive value of ECC were estimated by the exact binomial specimens were analyzed at the Department of Pathology of the method. Univariate analyses of the factors explaining the diagnostic University Hospital of Strasbourg. Histological findings were underestimation with ECC were made comparing continuous reported in accordance with the classification of Richart (14). variables with either the Student's t-test (when the variable of interest In accordance with the practice of our colposcopy Center, for was Gaussian), or a non-parametric test (Mann–Whitney–Wilcoxon). patients without severe cytological abnormalities, no treatment was Comparisons of qualitative variables were performed using a simple indicated in the case of a normal ECC, or in the case of CIN1 with logistic model. All tests were two-sided and a p-value of less than ECC if the colposcopy was satisfactory.
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